Incorporating MI techniques into physician counseling

Effect of a Coaching Intervention to Improve Cardiologist Communication: A Randomized Clinical Trial

Importance

Communication between cardiologists and patients can significantly affect patient comprehension, adherence, and satisfaction. To our knowledge, a coaching intervention to improve cardiologist communication has not been tested.

Objective

To evaluate the effect of a communication coaching intervention to teach evidence-based communication skills to cardiologists.

Design, Setting, and Participants

This 2-arm randomized clinical trial was performed at outpatient cardiology clinics at an academic medical center and affiliated community clinics, and from February 2019 through March 2020 recruited 40 cardiologists and audio recorded 161 patients in the preintervention phase and 240 in the postintervention phase. Data analysis was performed from March 2022 to January 2023.

Interventions

Half of the cardiologists were randomized to receive a coaching intervention that involved three 1:1 sessions, 2 of which included feedback on their audio-recorded encounters. Communication coaches taught 5 skills derived from motivational interviewing: (1) sitting down and making eye contact with all in the room, (2) open-ended questions, (3) reflective statements, (4) empathic statements, and (5) "What questions do you have?"

Main Outcomes and Measures

Coders unaware of study arm coded these behaviors in the preintervention and postintervention audio-recorded encounters (objective communication). Patients completed a survey after the visit to report perceptions of communication quality (subjective communication).

Results

Analysis included 40 cardiologists (mean [SD] age, 47 [9] years; 7 female and 33 male) and 240 patients in the postintervention phase (mean [SD] age, 58 [15] years; 122 female, 118 male). When controlling for preintervention behaviors, cardiologists in the intervention vs control arm were more likely to make empathic statements (intervention: 52 of 117 [44%] vs control: 31 of 113 [27%]; P = .05); to ask, "What questions do you have?" (26 of 117 [22%] vs 6 of 113 [5%]; P = .002); and to respond with empathy when patients expressed negative emotions (mean ratio of empathic responses to empathic opportunities, 0.50 vs 0.20; P = .004). These effects did not vary based on patient or cardiologist race or sex. We found no arm differences for open-ended questions or reflective statements and were unable to assess differences in patient ratings due to ceiling effects.

Conclusions and Relevance

In this randomized clinical trial, a communication coaching intervention improved 2 key communication behaviors: expressing empathy and eliciting questions. Empathic communication is a harder-level skill that may improve the patient experience and information comprehension. Future work should explore how best to assess the effect of communication coaching on patient perceptions of care and clinical outcomes and determine its effectiveness in larger, more diverse samples of cardiologists.

Trial Registration

ClinicalTrials.gov Identifier: NCT03464110.

“Sometimes It Felt Great, and Sometimes It Just Went Pear-Shaped”: Experiences and Perceptions of School Nurses’ Motivational Interviewing Competence: A Convergent Mixed-Methods Study

In this convergent mixed-methods study, the aim was to explore how objective and subjective quality ratings of school nurses’ motivational interviewing (MI) correlate whilst also considering the perceptions of delivering and participating in the same MI sessions. Quantitative and qualitative data were derived from seven intervention schools participating in the Healthy School Start Plus parenting support intervention. School nurses were trained in MI and conducted an MI session with parents of 6–7-year-old children to discuss children’s physical health and development. Quantitative data comprised objective ratings of school nurses’ MI competence using the Motivational Interviewing Treatment Integrity 4.2 [MITI-4] protocol, as well as parents’ and school nurses’ subjective ratings of the MI sessions. Qualitative data comprised semi-structured interviews with parents and school nurses about their perceptions of the MI sessions. First, quantitative data were analysed using Spearman’s rank correlation, and qualitative data were analysed using content analysis. Next, quantitative and qualitative findings were merged. Our findings suggest that school nurses’ MI performances were rated and perceived as valuable and family-centred by both school nurses and parents who had left the meeting feeling motivated and empowered to promote their children’s healthy behaviours. Nonetheless, school nurses were critical to their own MI technical performance, and they found that reflections were easier to deliver and to self-rate. Overall, MITI ratings were the lowest and parents’ ratings were the highest. Future studies should focus on relating clients’ subjective ratings of MI with clients’ behavioural outcomes.

Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior

OBJECTIVE

Motivational interviewing (MI) can promote behavior change, but HIV care providers rarely have training in MI. Little is known about the use of MI-consistent behavior among untrained providers. This study examines the prevalence of such behaviors and their association with patient intentions to reduce high-risk sexual behavior.

METHODS

Audio-recorded visits between HIV-infected patients and their healthcare providers were searched for counseling dialog regarding sexual behavior. The association of providers' MI-consistence with patients' statements about behavior change was assessed.

RESULTS

Of 417 total encounters, 27 met inclusion criteria. The odds of patient commitment to change were higher when providers used more reflections (p=0.017), used more MI consistent utterances (p=0.044), demonstrated more empathy (p=0.049), and spent more time discussing sexual behavior (p=0.023). Patients gave more statements in favor of change (change talk) when providers used more reflections (p<0.001) and more empathy (p<0.001), even after adjusting for length of relevant dialog.

CONCLUSION

Untrained HIV providers do not consistently use MI techniques when counseling patients about sexual risk reduction. However, when they do, their patients are more likely to express intentions to reduce sexual risk behavior.

PRACTICE IMPLICATIONS

MI holds promise as one strategy to reduce transmission of HIV and other sexually transmitted infections.

Comparing primary care physicians' smoking cessation counseling techniques to motivational interviewing

OBJECTIVES

This study examined the degree of similarity between motivational interviewing (MI) methods and smoking cessation techniques that are routinely used by primary care physicians. Its purpose was to inform the development of more effective MI-based health behavior change training programs for primary care physicians.

METHODS

Visits to primary care physicians were audio-recorded in northeast Ohio from 2005 to 2008. Doctor-patient talk about smoking cessation (n = 73) was analyzed for adherence to MI using the Motivational Interviewing Skills Code (MISC) version 2.1 behavioral coding system. Participating physicians were not provided with MI training as part of the study and were blinded as to the study's purpose.

RESULTS

Physicians displayed MI adherent behaviors in 56% of discussions and MI nonadherent behaviors in 57%. The most common MI adherent statements involved affirming the patient; least common were requests for the patient's permission before raising concerns. The most frequent MI nonadherent behaviors were directing, confronting, and warning the patient. Physicians made simple reflections and complex reflections in 36% and 25% of visits, respectively.

CONCLUSIONS

Physicians used both MI adherent and MI nonadherent behaviors in approximately equal proportions, suggesting a base of MI adherent smoking cessation counseling skills upon which additional MI skills can be built. Efforts to improve smoking-cessation effectiveness may involve providing training in brief MI models and additional MI skills, while reinforcing physicians' current use of MI adherent methods.